WITHDRAWAL AGREEMENT

Statement of Claim Number:

The statement below is provided to show agreement with the withdrawal submitted by water
right co-owner(s) received by the DNRC
on
.


Statement Signed by Owner:
I declare under penalty of perjury ( 45-7-201, MCA) under the laws of the state of
Montana that the foregoing content of this form is true and correct. I further declare that
I have the authority to sign this document for myself as an individual or in
representational capacity as an officer of a corporation, member of a limited liability
company, general partner of a limited partnership, trustee for a trust or other official
capacity for an entity as defined under person in 85-2-102, MCA. (All current
owners of the right as listed in the DNRC centralized record system are required
to sign. Please attach DNRCs Withdrawal Agreement form if additional owner
signatures are needed.)




(Date Signed) (Signature of Claimant) (Office or Title)



(Date Signed) (Signature of Claimant) (Office or Title)



(Date Signed) (Signature of Claimant) (Office or Title)



(Date Signed) (Signature of Claimant) (Office or Title)



(Date Signed) (Signature of Claimant) (Office or Title)



(Date Signed) (Signature of Claimant) (Office or Title)



(Date Signed) (Signature of Claimant) (Office or Title)



(Date Signed) (Signature of Claimant) (Office or Title)




Withdrawal Agreement
Page 1 of 1 Revised April 30, 2014